OHSU's Smile Doctor: Saving brain injury patients from isolation

Patient Jarm Hawes shows how she can move both sides of her face. The left side of her face had been paralyzed after she suffered a stroke. Courtesy: OHSU

When Jarm Hawes suffered a stroke in 2015, the physical effects were devastating. She couldn’t get around without a walker. Her left eye drifted, and the stroke paralyzed her face, leaving it twisted and slack.

With rehab work, she regained the ability to walk, and her eye started working better. But one thing she thought she’d lost permanently was a critical piece of her appearance.

Her smile.

“It was all this side dropped all the way down, and it was starting to twist,” Hawes says.

And even though she’d rehabbed through the physical effects and could walk again, her face remained paralyzed, and her new appearance had a deep mental impact.

“Because I’d look in the mirror and I didn’t see me anymore,” she says, “and I liked the old me. I liked the way I looked.”

“She described herself as a monster,” says OHSU’s Dr. Myriam Loyo, a surgeon, assistant professor, and member of the hospital’s new Facial Nerve Center. “I never saw her as a monster; she’s a beautiful, gorgeous woman, but that’s how she saw herself.”

Dr. Loyo thought she could help. Loyo is one of the few doctors on the West Coast who perform nerve transfer surgeries to reanimate faces that have been frozen by injury.

"To make her face move again, I needed to bring a nerve that had movement to the nerve that had no movement, so I stole some branches from the tongue nerve, to put into the face," Dr. Loyo explains. "Not only did I connect the tongue nerve to her face, I connected the other side of the face to the side that had paralysis so that she could have more spontaneous movement.

It’s a surgery not many people know about, including medical professionals. In fact, Hawes had seen several doctors and none of them knew about the procedure. It was when she visited an eye specialist that she heard there was another option.

And she found out in the nick of time; patients only have a year or less after brain or nerve injury before the facial nerves have atrophied too much and the surgery is no longer effective. If a year or more has passed, Dr. Loyo will recommend something else, a muscle and nerve transplant from the leg, which is also effective in returning muscle movement to the face, but requires a longer stay in the hospital and is a more intensive surgery.

Loyo has performed about 30 of the nerve transfer surgeries in three years. She knows there are many more people who could be helped. Common causes for facial paralysis include brain surgery, tumors, skin cancers, strokes, even trauma like car crashes.

“I suspect people that could benefit from it are not being offered the surgery,” she says. “When I went to medical school, these surgeries were not possible, so it’s something that we really need to work to educate our community of doctors, of patients, that we have new treatments for facial paralysis.”

And it’s a process that is still developing and getting better.

“The technologies, the surgeries, the treatments have really changed over the last decade,” Dr. Loyo says.

Nerve transfer surgeries usually take just a few hours.

Dr. Loyo says the incision is like what a person would get if they were having a face-lift. She doesn’t know what she’ll see nerve-wise until she gets inside.

“It’s literally incisions hidden in the side of your face, lifting and opening up the face, and looking at the facial nerves and muscles to reconnect them,” she explains.

The nerves are sometimes as small as hairs, and Dr. Loyo uses a surgical microscope to help her connect them.

“And then you go home, and we wait,” she advises her patients. “It takes a few months for the nerves to grow, then we can start seeing movement as early as 4 to 6 months after the surgery.”

She says patients are often not the first ones to see that their face is reanimated.

“I can see movement coming back a little bit earlier than the patients, and I think that sometimes the patients see the movement, but they don’t want to be too optimistic,” says Loyo. “It’s really rewarding when you start seeing some movement. The commissure just starts to elevate, and when we get a full smile, it’s really, really special. I love doing it!”

"Finding Dr. Loyo and the facial reanimation, I don't know where I'd be without it," says Hawes, who's resumed many of her favorite activities and recently married her boyfriend. "I can smile!"

To connect with OHSU’s Facial Nerve Center, click this link.

To learn more about Jarm Hawes's nerve transfer facial reanimation surgery, clink this link.

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